Additional Details for Disclosure Questions 1-11

Please specify the number of the question(s) for which you are giving additional details.



Chana (Wc

Name: | Date: q
Mark an "X" for each facility evaluated in the multiple site disclosure form ~
Covered Site City State

X__ |Princeton Plasma Physics Laboratory Princeton NJ
X [Project Chariot Site Cape Thompson AK
X {Project Faultless Nuclear Explosion Site Central Nevada Test Site INV
X__ [Project Gasbuggy Nuclear Explosion Site Farmington NM
X [Project Gnome Nuclear explosion Site Carlsbad NM
X__ [Project Rio Blanco Nuclear Explosion Site Rifle ico
X__ |Project Rulison Nuclear Explosion Site Grand Valley ico
X— [Project Shoal Nuclear Explosion Site Fallon INV
X [Puerto Rico Nuclear Center Mayaguez PR
X [Purdue University Lafayette IN
X [Quality Hardware and Machine Co. Chicago IL
X JR. Krasburg and Sons Manufacturing Co. Chicago IL
X__|R.W. Leblond Machine Tool Co. Cincinnati OH
X__ {Radium Chemical Co. New York NY
X___|Rare Earth/W. R. Grace Wayne NJ
X___|Reed Rolled Thread Co. Worcester MA
X___|Revere Copper and Brass Detroit MI
X___|Rocky Flats Plant Golden co
X___}Roger Iron Co. Joplin IMO.
X__|Sacandaga Facility Glenville INY
X [Salmon Nuclear Explosion Site Hattiesburg MS
X___|Sandia Laboratory-Salton Sea Base Imperial County ICA
X___|Sandia National Laboratory Albuquerque NM
X___|Sandia National Laboratories - Livermore Livermore ICA
X__|Savannah River Site Aiken SC
X__|Sciaky Brothers, Inc. Chicago IL
X _ |Seaway Industrial Park Tonawanda NY
X _ |Separations Process Research Unit (at Knolls Lab) Schenectady NY
X Seymour Specialty Wire Seymour CT
X [Shattuck Chemical Denver (eo)
X__|Shippingport Atomic Power Plant 'Shippingport PA
X__|Shpack Landfill Norton MA
X {Simonds Saw and Steel Co. Lockport NY
X [South Albuquerque Works Albuquerque NM
X_—_|Southern Research Institute Birmingham AL
X [Spencer Chemical Co., Jayhawks Works Pittsburg KS
X__ [Sperry Products, Inc. Danbury CT
X__|StLouis Airport Storage Site (SLAPS) St. Louis IMO
X [Standard Oil Development Co. of NJ Linden NJ
X__ {Stanford Linear Accelerator Center Palo Alto ICA
X [Star Cutter Corp. Farmington MI
X___}Staten Island Warehouse New York NY
X___|Stauffer Metals, Inc. Richmond CA
X [Superior Steel Co. Carnegie PA
X — [Sutton, Steele and Steele Co. Dallas TX
X {Swenson Evaporator Co. Harvey IL
X [Sylvania Corning Nuclear Corp - Bayside Laboratories Bayside NY
X__ {Sylvania Corning Nuclear Corp - Hicksville Plant Hicksville NY
X_[Tech-Art, Inc. Milford OH



Name: Chang (hia Date: Yh, o

d
Mark an "X" for each facility evaluated in the multiple site disclosure form

| Covered Site City State

X__ [Bowen Engineering, Inc. North Branch INJ
X [Bridgeport Brass Co., Adrian Adrian MI

X___|Bridgeport Brass Co., Havens Lab Bridgeport CT
X [Brookhaven National Laboratory Upton INY
X {Brush Beryllium Co. 1 Detroit MI

X___ {Brush Beryllium Co. 4 Cleveland OH
X__|C-B Tool Products Co. Chicago IL

X__|C.G. Sargent & Sons Graniteville MA
XC. H. Schnorr Springdale PA
X__ IC. |. Hayes, Inc. Cranston RI

X__ [California Research Corp. Richmond CA
X__|Callite Tungsten Co. ‘Union City INJ
X___|Carboloy Co. Detroit MI

X [Carnegie Institute of Technology Pittsburgh IPA
X__ |Carpenter Steel Co. Reading PA
X__|Chambersburg Engineering Co. Chambersburg PA
X__ {Chapman Valve Indian Orchard MA
X__|Chemical Construction Co. Linden NJ
X  |Chupadera Mesa Chupadera Mesa NM
X [Cincinnati Milling Machine Co. Cincinnati OH
X [Clarksville Facility Clarksville TN
X [Colonie Site (National Lead) ‘Colonie (Albany) NY
X [SAM Laboratories, Columbia University INew York City NY
X [Combustion Engineering Windsor CT
X {Connecticut Aircraft Nuclear Engine Laboratory Middletown CT
X__ |Copperweld Steel Warren OH
X [Crane Co. Chicago IL

X {Crucible Steel Co. Syracuse NY
X — |Dana Heavy Water Plant Dana IN

X [Dorr Corp. Stamford CT
X__ {Dow Chemical Co. Walnut Creek CA
X [Du Pont - Grasselli Research Laboratory Cleveland OH
X__ [Du Pont Deepwater Works Deepwater NJ
X__JERA Tool and Engineering Co. Chicago IL

X [Edgerton Germeshausen & Grier, Inc. Boston MA
X_ Electro Circuits, Inc. Pasadena iCA
X__ Electro Metallurgical Niagara Falls NY
X___|Elk River Reactor Elk River MN
X— [Area IV of the Santa Susana Field Laboratory Santa Susana CA
X__ Environmental Measurements Laboratory New York NY
X [Extruded Metals Co. Grand Rapids MI

X___}Extrusion Plant (Reactive Metals Inc.) Ashtabula OH
X_ |Feed Materials Production Center (FMPC) Fernald OH
X [Fenn Machinery Co. Hartford CT
X__|Fenwal, Inc. Ashland MA
X___|Fermi National Accelerator Laboratory Batavia IL

X__ [Foote Mineral Co. East Whiteland Twp. PA
X [GSA 39th Street Warehouse Chicago IL

X — |Gardinier, Inc. Tampa EL.



Name:
Mark an "X" for each fa

Cho nq (hia

;
Date: h

ity evaluated in the multiple site disclosure form

Y200r)

Covered Site City State

X__ JAC Spark Plug Flint MI
X__J|AMCOT Fort Worth TX
X___|Aeroprojects, Inc. West Chester PA
X__ {Ajax Magnathermic Corp. Youngstown OH
X_ {Alba Craft Oxford OH
X___|Albany Research Center Albany OR
X__ [Albuquerque Operations Office ‘Albuquerque NM
X_ [Aliquippa Forge ‘Aliquippa PA
X__{Allegheny-Ludium Steel Watervliet NY
X__ |Allied Chemical Corp. Plant Metropolis IL
X__ Allied Chemical and Dye Corp. North Claymont DE
X__ jAllis-Chalmers Co. West Allis, Milwaukee WI
X [Aluminum Co. of America (Alcoa) 1 New Kensington PA
X__}Aluminum Co. of America (Alcoa) 2 Garwood NJ
X__ |Amchitka Island Nuclear Explosion Site Amchitka Island AK
X___jAmerican Bearing Corp. Indianapolis IN
X__ {American Chain and Cable Co. Bridgeport CT
X___ American Machine and Foundry Brooklyn NY
X__ {American Machine and Metals, Inc. E. Moline IL
X__ [American Peddinghaus Corp. Moonachle NJ
X__|American Potash & Chemical West Hanover MA
X___|Ames Laboratory [Ames IA
X__ jAnaconda Co. Waterbury CT
X_{Argonne National Laboratory - East Argonne IL
X___JArgonne National Laboratory - West Scoville ID
X__|Armco-Rustless Iron and Steel Baltimore MD
X_ {Armour Fertilizer Works Bartow FL
X [Armour Research Foundation Chicago IL
X__ Arthur D. Little Co. San Francisco CA
X__ JAshland Oil Tonawanda NY
X__ Associated Aircraft Tool and Manufacturing Co. Fairfield OH
X__|B&T Metals Columbus OH
X__ BONUS Reactor Plant Punta Higuera PR
X  |BWXT Lynchburg IVA.
X_|Baker Brothers Toledo OH
X___|Baker and Company Newark NJ
X___|Baker and Williams Warehouses New York NY
X_ [Baker-Perkins Co. Saginaw MI
X__ [Battelle Laboratories - King Avenue Columbus OH
X__ [Battelle Laboratories - West Jefferson Columbus OH
X [Bell Telephone Laboratories Murray Hill INJ
X__ [Bendix Aviation (Pioneer Division) Davenport IA
X___ {Beryllium Production Plant (Brush) Luckey OH
X__ [Besley-Wells South Beloit WI
X__|Bethlehem Steel Lackawanna NY
X__|Birdsboro Steel & Foundry Birdsboro PA
X__ [Bliss & Laughlin Steel Buffalo NY
X__|Blockson Chemical Co. (Building 55 and related activities) Joliet IL
X_ [Bloomfield Tool Co. Bloomfield NJ



Uf

Name: ¢ Date: 78/2907
Mark an "X" for each facility evaluated in the multiple site disclosure form
Covered Site City State

X__ Lovelace Respiratory Research Institute Albuquerque NM
X {DOW Chemical Co. (Madison Site) Madison IL
X__ |Magnus Brass Co. Cincinnati OH
X__|Mallinckrodt Chemical Co., Destrehan St. Plant St. Louis IMO
X [Massachusetts Institute of Technology Cambridge MA
X___|Mathieson Chemical Co. Pasadena TX
X___|Maywood Chemical Works Maywood NJ
X___|McKinney Tool and Manufacturing Co. Cleveland OH
X__|Medart Co. St. Louis MO
X___|Medina Facility San Antonio TX
X___|Metals and Controls Corp ‘Attleboro MA
X_— |Middlesex Municipal Landfill Middlesex NJ
X {Middlesex Sampling Plant Middlesex NJ
X {Midwest Manufacturing Co. Galesburg IL
X___|Mitchell Steel Co. Cincinnati OH
X___|Mitts & Merrel Co. Saginaw MI
X__ [Monsanto Chemical Co. Dayton OH
X {Mound Plant Miamisburg OH
X [Museum of Science and Industry Chicago IL
X [National Bureau of Standards, Van Ness Street Washington IDC
X___ [National Guard Armory Chicago IL
X___|National Research Corp. Cambridge MA
X___|Naval Research Laboratory Washington DC
X__ {Nevada Test Site Mercury NV
X___ |New Brunswick Laboratory New Brunswick NJ
X__ |New England Lime Co. Canaan CT
X |New York University New York NY
X__|Norton Co. Worcester MA
X_— [Nuclear Materials and Equipment (NUMEC) - Parks Township Parks Township PA
X_— [Nuclear Materials and Equipment Corp. (NUMEC) - Apollo ‘Apollo IPA
xX Nuclear Metals, Inc. Concord MA
X [Oak Ridge Gaseous Diffusion Plant (K-25) Oak Ridge TN
X [Oak Ridge Hospital Oak Ridge TN
X__ |Oak Ridge Institute for Science Education Oak Ridge TN
X_— |Oak Ridge National Laboratory (X-10) Oak Ridge TN
X [Oliver Corp. Battle Creek MI
X___|Pacific Northwest National Laboratory Richland WA
X__ |Pacific Proving Ground Marshall Islands MH
X___|Paducah Gaseous Diffusion Plant Paducah KY
X_— |Painsville Site (Diamond Magnesium Co.) Painsville OH
X___|Pantex Plant Amarillo TX
X___|Peek Street Facility Schenectady NY
X__|Penn Salt Co. Philadelphia / Wyndmoor PA
X [Philadelphia Naval Yard Philadelphia PA
X_ {Pinellas Plant Clearwater EL:
X___|Piqua Organic Moderated Reactor Piqua OH
X___|Podbeliniac Corp. Chicago IL
X___|Portsmouth Gaseous Diffusion Plant Piketon OH
X__ {Precision Extrusion Co. Bensenville IL



Conflict or Bias Disclosure Form

Identification

{

( MOUN4) C

Name of Individual or Corporate Entity:

Name of Employer: /\\) /)S/+

Today's Date: D 7)

Sites/Facilities addressed on this form: /| (|

Questions to Identify a Conflict or Bias

4. Are you’ currently engaged in any capacity (paid or unpaid) by the U.S. Department of
Energy (DOE)? Check Yes or No.

“Site” and “facility” are defined to include DOE, AWE and other federally-owned or -operated sites. For
purposes of brevity, the "other federally-owned or -operated sites" category shall be referred to in this
document as “other” sites.

Yes___, aCOB exists and the individual with the COB cannot perform any key Program
function for any site. If yes, please provide details about each DOE location (specific site or sites)
at which you are currently engaged, a description of your activities for DOE, and whether you are
paid or unpaid. Stop.

No proceed to Question 2.

2. Do you, or did you, work either at or for this DOE or Atomic Weapons Employer (AWE)
site? Check Yes or No.

"Work" means employment at or for the site, site contractor or site subcontractor that includes
management, direction, or implementation of radiation protection and/or health physics program policies,
procedures or practices related to atomic weapons activities at the site.

Yes , aCOB exists and the individual with the COB cannot perform a key Program
function related to this site or sites. Please provide details below about the DOE or AWE site(s)
you work/worked at or for. Stop.

}
No L , proceed to Question 3.

‘For purposes of completing this form, “you” refers to an individual or an employer (depending on which
party is completing the form).


Mia

Chang

Name: 5

Mark an "X" for each facility evaluated in the multiple site disclosure form /

| I Covered Site City State
X | Tonopah Test Site North Las Vegas NV
X___ JOre Buying Station at Globe Globe AZ
X {Green Sludge Plant Uraven (ee)
X [Uranium Mill in Durango Durango co
X__|Ore Buying Station at Grants Grants NM
X__ |Ore Buying Station at Shiprock Shiprock NM
X__ |Ore Buying Station at Edgemont Edgemont SD
X___|Ore Buying Station at Marysvale Marysvale UT
X_ [Ore Buying Station at Moab Moab UT
X__ Ore Buying Station at Monticello Monticello UT
X__ Ore Buying Station at White Canyon White Canyon UT
X_—_ [Uranium Mill in Monticello Monticello UT
X___}Ore Buying Station at Crooks Gap Crooks Gap WY
X__ Ore Buying Station at Riverton Riverton iwY
X__ |General Electric X-Ray Division Milwaukee WI
X___|Nevada Site Office North Las Vegas NV
X__|High Energy Rate Forging (HERF) Facility Oxnard CA
X_|Mill at Moab Utah Moab UT
X [Clinton Engineer Works (CEW) Oak Ridge ITN
X__|Canoga Avenue Facility (Vanowen Building) Los Angeles CA
X__ {De Soto Avenue Facility Los Angeles CA
X [Downey Facility Los Angeles CA
X__ Kirtland Operations Office ‘Albuquerque NM
X [Ross Aviation Albuquerque NM



Al

(| fa

Date: la. 07

Name: CVA

Mark an "X" for each facility evaluated in the multiple site disclosure form

| : Covered Site City State
X__ [Tennessee Valley Authority Muscle Shoals AL
X__|Texas City Chemicals, Inc. Texas City TX
X___| Thomas Jefferson National Accelerator Facility Newport News VA
X__ [Titanium Alloys Manufacturing Niagara Falls NY
X___|Titus Metals Waterloo IA
X [Tocco Induction Heating Div Cleveland OH
X [Torrington Co. Torrington CT
X__ Trinity Nuclear Explosion Site White Sands Missile Range _|NM
X_ |Tube Reducing Co. Wallington NJ
X__ [Tyson Valley Powder Farm St. Louis MO
X__JU-S. Steel Co., National Tube Division McKeesport PA
X__|United Lead Co. Middlesex NJ
X [United Nuclear Corp. Hematite MO.
X___|University of California Berkeley CA
X__ {Metallurgical Laboratory Chicago IL
X__|University of Denver Research Institute Denver ICO
X___ [University of Florida Gainesville FL
X__ {University of Michigan Ann Arbor MI
X__ [University of Rochester Atomic Energy Project Rochester NY
X__ {University of Virginia Charlottesville VA
X_|Utica St. Warehouse Buffalo NY
X__.|Ventron Corporation Beverly MA
X__ |Virginia-Carolina Chemical Corp. Nichols FL
X__ [Vitro Corp. of America, Chattanooga Chattanooga TN
X__ |Vitro Corp. of America, West Orange West Orange NJ
X__ }Vitro Manufacturing Canonsburg PA
X__ [Vulcan Tool Co. Dayton OH
X__|W.E. Pratt Manufacturing Co. Joliet IL
X_|W.R. Grace Erwin TN
X |W. R. Grace Co., Agricultural Chemical Div. Ridgewood FL
X__|W.R. Grace and Company Curtis Bay MD
X [Wah Chang ‘Albany OR
X__|Waste Isolation Pilot Plant Carlsbad NM
X___|Watertown Arsenal Watertown MA
X [Weldon Spring Plant Weldon Spring MO
X_— |West Valley Demonstration Project West Valley NY
X_— |Westinghouse Atomic Power Development Plant East Pittsburgh PA
X__ {Westinghouse Electric Corp. Bloomfield NJ
X [Winchester Engineering and Analytical Center Winchester MA
X___|Woburn Landfill }Woburn MA
X [Wolff - Alport Chemical Corp. Brooklyn NY
X__ |Wolverine Tube Division Detroit MI
X [Wyckoff Drawn Steel Co. Chicago IL
X___|Wykoff Steel Co. Newark NJ
X___}Y-12 Plant Oak Ridge TN
X___ Yucca Mountain Site Characterization Project Yucca Mountain NV
X  |Carborundum Company Niagara Falls NY
X__|Oak Ridge Thermal Diffusion Plant (S-50) Oak Ridge TN
X [Westinghouse Nuclear Fuels Division Cheswick PA



Name: ( \ AN u Date: i 5.
Mark an "X" for each facility evaluated in the multiple site disclosure form 12067
Covered Site City State

X__ |General Atomics La Jolla CA
X__ |General Electric Company Cincinnati / Evendale OH
X__ |General Electric Plant Shelbyville IN
X__ |General Electric Vallecitos Pleasanton ICA
X {Grand Junction Operations Office Grand Junction icO
X__ |General Steel Industries Granite City IL
X [Great Lakes Carbon Corp. Chicago IL
X__|Gruen Watch Norwood OH
X__|Hallam Sodium Graphite Reactor Hallam NE
X__|Hanford Richland WA
X__|Harshaw Chemical Co. Cleveland OH
X__|Heald Machine Co. Worcester MA
X__ |Heppenstall Co. Pittsburgh PA
X___|Herring - Hall Marvin Safe Co. Hamilton OH
X___ [Hooker Electrochemical Niagara Falls INY
X___|Horizons, Inc. Cleveland OH
X — |Hunter Douglas Aluminum Corp. Riverside ICA
X__|Huntington Pilot Plant Huntington WV
X___ {Idaho National Laboratory ‘Scoville ID
X___|International Minerals and Chemical Corp. Mulberry FL
X__ [International Nickel Co., Bayonne Laboratories Bayonne NJ
xX International Rare Metals Refinery, Inc. Mt. Kisco NY
X__|International Register Chicago IL
X___ |lowa Ordnance Plant Burlington IA
X_|lthaca Gun Co. Ithaca NY
X__ |J. T. Baker Chemical Co. Phillipsburg NJ
X [Jessop Steel Co. Washington PA
X [Joslyn Manufacturing and Supply Co. Ft. Wayne IN
X [Kaiser Aluminum Corp. Dalton IL
X [Kansas City Plant Kansas City MO
X_ |Kauai Test Facility Kauai HI
X__ |Kellex/Pierpont Jersey City © INJ
X__ Kerr - McGee Guthrie OK
X__ [Koppers Co., Inc. Verona PA
X__|La Pointe Machine and Tool Co. Hudson MA
X__ {LaCrosse Boiling Water Reactor LaCrosse WI
X__ |Laboratory for Energy-Related Health Research Davis CA
X__ {Laboratory of Biomedical and Environmental Sciences Los Angeles CA
X Laboratory of Radiobiology and Environmental Health San Francisco CA
X_— |Lake Ontario Ordnance Works Niagara Falls NY
X__ {Landis Machine Tool Co. Waynesboro PA
X___|Latty Avenue Properties Hazelwood MO
X__ jLawrence Berkeley National Laboratory Berkeley CA
X__ jLawrence Livermore National Laboratory Livermore ICA
X___|Linde Air Products Buffalo NY
X___|Linde Ceramics Plant ‘Tonawanda NY
X__ Lindsay Light and Chemical Co. IW. Chicago IL
X___|Los Alamos Medical Center Los Alamos NM
X___|Los Alamos National Laboratory Los Alamos NM



9. Do you have a familial relationship, or supervisory or subordinate work relationship with
anyone who has had an impact related to the site? Check Yes or No.

Yes , then proceed to Question 10.

No lL , then proceed to Question 11.

10. If you have a subordinate relationship to someone who has (had) an impact on the site,
has a different person been designated to review your job performance as it relates to the
site? Check Yes or No.

Yes___, a COB does not exist. Proceed to Question 11.

No , then a COB exists and the individual with the COB cannot perform a key Program
function for this site or sites. Please provide more detailed information about your relationship
with the person having an impact on the site. Stop.

11. Do or did you have a familial, financial or non-financial professional (e.g., providing
expert advice) relationship with any attorney at the time the attorney represented an
EEOICPA claimant, DOE or the operator?

Yes , then a COB exists and the individual with the COB cannot perform a key Program
function for this site or sites. Please provide details about the relationship with the attorney, to
include (if applicable) a list of cases for which you assisted the attorney as well as the names of
parties on whose behalf you testified or otherwise provided assistance. Stop.

No , then a COB does not exist.


No 7 , proceed to Question 8.

7. Did your work for DOE have an impact on this site? Check Yes or No.

“Impact” means that your work involved decision-making authority over management, direction, or
implementation of radiation protection and/or health physics program policies, procedures or practices
related to atomic weapons activities at the site.

Yes , then a COB exists and the individual with the COB cannot perform a key Program
function for this site or sites. Please provide details below about the nature of the impact your
work for the operator had on the site. Stop.

No , then proceed to Question 8.

8. Do you have a familial relationship, or a supervisory or subordinate work relationship
with an EEOICPA claimant whose claim involves this site? Check Yes or No.

“Familial relationship” encompasses a current spouse, child, parent, sibling or grandparent that worked at or
for the site; or any survivors a current spouse, child, parent, sibling or grandparent that are eligible to file
claims under the Program.

“Supervisory or subordinate work relationship” is one where (a) the individuals in question are/were in the
same reporting chain and within two organizational levels of one another; and (b) "Work" means
employment at or for the site, site contractor or site subcontractor that includes management, direction, or
implementation of radiation protection and/or health physics program policies, procedures or practices
related to atomic weapons activities at the site.

Yes , then a COB exists and the individual with the COB cannot perform a key Program
function for this site or sites. Please provide below details about the nature of your relationship
with the EEOICPA claimant. Stop.

No , then proceed to Question 9.


3. Do you, or did you, work for any of the past or current operators of this site? Check Yes
or No.

"Operator" refers to the governmental and/or corporate entities responsible for performing and overseeing
day-to-day activities at the site, and includes work, as defined above, performed by the operator's
(sub)contractors

Yes , provide the names of the past or current operators, the name of the site that the
operator did or does administer and the specific times (starting and stopping dates) that you
worked, or continue to work, for the operator and proceed to Question 4.

No | , proceed to Question 6.

4. During the time you worked for that operator, was that operator responsible for this
site? Check Yes or No.

Yes , proceed to Question 5. No , proceed to Question 6.

5. Did your work for the operator have an impact on this site? Check Yes or No.

“Impact” means that your work involved decision-making authority over management, direction, or
implementation of radiation protection and/or health physics program policies, procedures or practices
telated to atomic weapons activities at the site.

Yes , then a COB exists and the individual with the COB cannot perform a key Program

function for this site or sites. Please provide details about the nature of the impact your work for
the operator had on the site below. Stop.

No , proceed to Question 6.

6. Did you work for DOE in the past? Check Yes or No.

"Work for DOE" does not include work, as defined above, for DOE of less than four months’ continuous
duration as a student intern, graduate fellow or in another primarily educational capacity. It also does not
include having received a financial stipend from DOE for graduate study, a fellowship in the context of an
established DOE fellowship program intended to support graduate-level work, or receipt of a federal
government retirement pension for prior DOE service.

Yes , please provide details about each DOE location (specific site or sites) you worked
for in the past and a description of your work for DOE (you-may use a checklist listing DOE/AWE
sites) and then proceed to Question 7.